Agenda. Medicare Part C and Part D Investigation Missions. Division of Plan Oversight and Accountability Updates
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1 Division of Plan Oversight and Accountability Updates ICE December 5, 2017 Beth Brady Investigations and Audit Group Center for Program Integrity Agenda Medicare Parts C and D Investigation Missions PLATO Current schemes in Medicare Part C and in Part D What s New in Data Analysis? 2 Medicare Part C and Part D Investigation Missions 3 1
2 Investigation Missions In an effort to provide Program Integrity updates to Medicare Parts C and D plan sponsors, the Center for Program Integrity hosted two collaboration missions this year. Participants included representatives from a small number of plans Special Investigation Units (SIU). 4 Investigation Missions The purpose of the missions is to: Share current schemes, trends, investigations and anti FWA activities Identify areas for targeted investigations and data analysis. Engage participation from representatives in the plan sponsor s SIUs in sharing their best practices. 5 Investigation Missions CPI collaboration mission included the following discussion topics Updates on emerging trends in healthcare fraud from the Office of Investigation, Office of Investigations (OIG/OI) Data analytic updates from the National Benefit Integrity (NBI) MEDIC and the Center for Program Integrity (CPI) Potential fraud scenarios and investigative best practices was shared among Medicare Parts C and D plan sponsors. Opioid Panel discussion by Medicare Parts C and D plans 6 2
3 Investigation Missions The feedback from the attendees was very positive We are in the early planning stages for additional missions in Our intent will be to invite those responsible for the anti fraud efforts at the plans. 7 Data PLATO Analysis 8 PLATO PLATO is a voluntary web based platform which serves three primary functions and facilitates: Sharing of national proactive data projects with plan sponsors Tracking of actions taken by plan sponsors Review of other plan sponsor actions taken against same subjects 9 3
4 Benefits of PLATO Allows for the review of high risk Medicare Part D pharmacies and providers identified by data projects Makes national data available and shares actions taken by other Medicare Advantage and Part D plan sponsors Provides data for all Part D pharmacies and providers and additional details on those identified as high risk leads FPS could also use plan sponsor actions to further refine models, and also use the data To the extent that MA and PDP plans exist, PLATO allows plan sponsors to share information regarding subject providers indefinitely without providing Parts A & B data 10 PLATO Data Projects and Reports Data Projects Quarterly Reports Pill Mill 1.0 and 2.0 Trio 1.0 and 2.0 Anti HIV Prescriber Anti HIV Pharmacy 1.0 and 2.0 Compounded Drug Pharmacy Doctor Shopper Prescriber Brand Name Pharmacy Stimulants Prescriber AAP Pharmacy 1.0 and 2.0 AAP Prescriber Outlier Prescriber High Risk Pharmacy Drug Trend Analysis Current Schemes Affecting Part C and Data Analysis Part D 12 4
5 Current Schemes Affecting Medicare Part C and Part D Sober Homes and Alcohol and Drug Addiction and Treatment Centers Drug Seeking Beneficiaries July 2017 National Health Care Fraud Takedown 13 What is New Data in Analysis Data Analysis? 14 What s New in Data Analysis CPI develops quarterly reports to assist Medicare Parts C and D plan sponsors with their monitoring and oversight efforts of FWA activities. Drug Trend Analysis Outlier Prescribers of Schedule II Pharmacy Risk Assessment 15 5
6 What s New in Data Analysis Sponsors should use the information to augment their current monitoring processes established to meet Part D program requirements. Sponsors should also utilize their own data analysis to identify trends and develop more focused audits. 16 Questions Contact information: Beth Brady Elizabeth.Brady@cms.hhs.gov
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